AZ BCBS Form 130783 2015-2025 free printable template
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Blue Cross Blue Shield of Arizona Provider Change Form NOTE readdress changes: If BCB SAZ does not receive a new address from the provider in writing, BCB SAZ will continue sending correspondence,
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How to fill out AZ BCBS Form 130783
How to fill out AZ BCBS Form 130783
01
Obtain the AZ BCBS Form 130783 from the appropriate source.
02
Read the instructions carefully before filling out the form.
03
Fill in your personal information, including your name, date of birth, and address.
04
Provide your insurance policy number in the designated section.
05
Complete the required medical history questions honestly.
06
Sign and date the form to verify the information is accurate.
07
Submit the form to the specified address or through the stated method.
Who needs AZ BCBS Form 130783?
01
Individuals applying for health insurance coverage in Arizona.
02
Residents seeking to enroll in Blue Cross Blue Shield plans.
03
Patients requiring prior authorization for medical services.
04
Anyone needing to report changes in their insurance status or personal information.
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People Also Ask about
What is the timely filing for BCBS Arizona?
NON-CONTRACTED PROVIDERS: Initial Claim: 6 months from the date of service (If HCP is primary, the claim timeliness changes to 7-months from the date of service or eligibility date). Corrected Claim: 12 months from the date of service. Corrected Claim:12 months from the date of service.
How do I contact Blue Cross Blue Shield of Arizona?
Call your closest office: (602) 864-4884, or toll-free (800) 232-2345, ext. 4884 Do you speak Spanish? Our service department does, too.
What is the timely filing limit for BCBS Arizona provider appeal?
BCBSAZ provider grievance process: Second-level review The second-level grievance must be submitted in writing to BCBSAZ within 60 calendar days after receipt of the first-level grievance determination. A provider may extend the 60-day time period for up to an additional 60 calendar days.
What is the timely filing limit for BCBS Arizona appeal?
Contract breach dispute resolution process The provider may request reconsideration in writing (including relevant information) no later than 30 calendar days after receipt of the notice from BCBSAZ.
What is the phone number for Blue Cross of Arizona provider?
Call customer service at (602) 864-4400, (800) 232-2345, ext. 4400, or the number on the back of your BCBSAZ ID card.
What is the timely filing limit for BCBS IL provider appeal?
You must file your appeal within 60 calendar days from the date on the Notice of Action letter.
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What is AZ BCBS Form 130783?
AZ BCBS Form 130783 is a form used by Blue Cross Blue Shield of Arizona for reporting health insurance information in compliance with state and federal regulations.
Who is required to file AZ BCBS Form 130783?
Entities such as health insurance providers, employers with self-insured health plans, and other organizations that offer health insurance coverage in Arizona are required to file AZ BCBS Form 130783.
How to fill out AZ BCBS Form 130783?
To fill out AZ BCBS Form 130783, start by gathering all necessary information related to health coverage, including policyholder details, coverage dates, and premium amounts. Fill in each section of the form accurately, ensuring all required fields are completed.
What is the purpose of AZ BCBS Form 130783?
The purpose of AZ BCBS Form 130783 is to collect essential data for regulatory compliance, claims processing, and to provide the state with information necessary for monitoring health insurance coverage in Arizona.
What information must be reported on AZ BCBS Form 130783?
AZ BCBS Form 130783 requires reporting information such as the policyholder's name, coverage type, effective dates of coverage, premium amounts, and any other pertinent details related to the health insurance plan.
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